Healthcare Provider Details

I. General information

NPI: 1285023267
Provider Name (Legal Business Name): MICHAEL QUINTANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 8TH ST
LAS VEGAS NM
87701-4251
US

IV. Provider business mailing address

614 8TH ST
LAS VEGAS NM
87701-4251
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-3644
  • Fax: 505-454-0787
Mailing address:
  • Phone: 505-425-3644
  • Fax: 505-454-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: